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This chapter focusses on topics that are often the subject of statutory and mandatory training sessions: infection control, safeguarding, blood transfusion. Whilst not perhaps as interesting as clinical dilemmas, they are important in terms of patient safety. The chapter ends with some MCQs to help you to refresh your memory of the newer agents used to prevent venous thromboembolism.
Theatre list management: infection control
You are anaesthetizing for a vascular list and there has been a below knee amputation added at the beginning of the list. On assessing the patient you establish they have cellulitis and are MRSA positive. They are isolated on the ward and barrier nursed. There are also two fem-pop bypasses on the list.
The most appropriate plan to be made at the morning team briefing is?
a) Postpone the amputation until the patient has completed MRSA eradication and has had two sets of negative swabs
b) Run to the order of the list but inform theatre staff of the positive MRSA status of the first patient and recommend everyone uses gloves and aprons
c) Run to the order of the list but have the theatre deep cleaned and left empty for 60 minutes following the infected case
d) Suggest to the surgeons that the order of the list should be changed to put the infected case at the end of the day
e) Suggest that the infected case be postponed to a list with other ‘dirty’ procedures in order that the two ‘clean’ cases can proceed without additional risk of cross-infection
Answer: d)
Anaesthetists will be involved in the care of patients who may be actively infected with, or carriers of, pathogenic organisms. This may or may not be known to them. Therefore, infection control precautions should be routine practice. Trusts should have Infection Control committees and teams that are responsible for making policies and monitoring compliance. A member of the anaesthetic department should be identified as lead for infection control. It is their responsibility to liaise with the Trust’s infection control teams and occupational health to ensure relevant standards are established and monitored in all areas of anaesthetic practice.
There should be a Trust policy that covers management of known infected cases coming to theatres. This would likely govern the local management of this example. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommendation is that there is a policy requiring accurate printed theatre lists to be available before the date of surgery. ‘Dirty’ cases should be identified before surgery and staff notified. These cases should be scheduled last on a list to minimize risk. Where this is not possible the Hospital Infection Society (HIS) advises that a plenum-ventilated operating theatre should require a minimum of 15 minutes before proceeding to the next case following a ‘dirty’ operation. Other recommendations include:
Standard precautions for every case, including single-use gloves. Additional precautions for specific procedures and patients including fluid-resistant masks with face shields and gowns.
Appropriate cleaning of the operating theatre between all patients, which includes surfaces of anaesthetic machines and monitoring equipment, particularly when visibly soiled.
Local policies to govern the cleaning with detergent of equipment not in contact with patients on a daily basis.
Movement into and out of the theatre complex to be kept to a minimum and doors shut to aid ventilation systems.
Bed linen to be handled with care and bagged by the bed or trolley to reduce the release of small fomite particles into the air.
Further reading
Safeguarding: child protection
A 7-year-old girl presents to the paediatric day case unit for dental extractions. While examining her airway you notice a torn and bruised upper labial frenulum, sub-aponeurotic haematoma and also some bruising on her right arm. Her mother says the girl fell off her bike 2 days ago causing these injuries.
Your actions should include which of the following?
a) Take a history and examine the child fully, documenting your findings carefully
b) Inform your consultant or manager and the local child protection team that you are concerned the girl is being abused
c) The injuries are consistent with the history given by the mother: therefore take no further action and proceed with the anaesthetic
d) Contact the police, as these injuries are indicative of physical abuse and the child may be in immediate danger
e) Check with social services whether the child’s name appears on the child at risk register
Answer: b)
It is not uncommon for children presenting for multiple dental extractions to be experiencing some form of neglect. Their parents or guardians are responsible for ensuring the child has an appropriate diet and adequate dental hygiene. In this case, however, it is physical abuse that is suspected.
The mother’s history does not fit with the injuries. A torn labial frenulum is a sign of potential child abuse if there is no history that is consistent with the injury. A sub-aponeurotic haematoma is a sign suggesting that the girl’s hair has been pulled with considerable force.
As a result of the Laming enquiry into the death of Victoria Climbié it was deemed that everyone involved in the care of children in the UK has a responsibility to act if child abuse is suspected. All NHS Trusts must have a named lead for child protection, and often this named lead will be part of a child protection team. The child protection team is able to coordinate a response to a child protection enquiry and appoint experienced personnel to undertake a full examination of the child.
To avoid unnecessary distress for the child and to ensure that physical signs are not missed, it is advisable that the child is fully examined once and by an experienced trained member of the child protection team. It could be argued that to check whether the child’s name appears on the child at risk register would be helpful and worthwhile, but in practice this is often a time-consuming task.
Prior to specialist child protection teams being established, the distribution of information between the hospital, general practitioner and various agencies could be a challenging process. Child protection teams are able to coordinate this much more efficiently.
Further reading
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